- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $4,934.49 / $5,181.30
| Facility | | $3,940.00 | $4,934.49 | $5,181.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.73 / $1,139.45 / $1,660.99
| Professional | | $846.73 | $1,139.45 | $1,660.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.67 / $1,251.77 / $1,803.13
| Professional | | $842.67 | $1,251.77 | $1,803.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,627.42 / $2,627.42 / $2,627.42
| Facility | | $2,627.42 | $2,627.42 | $2,627.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.36 / $1,198.36 / $2,063.29
| Professional | | $775.36 | $1,198.36 | $2,063.29 |